A hurricane of change is already upon us, but the fundamental doctor-patient relationship may just be the constant that preserves the integrity of medicine.
I told my Grandma, a very wise woman indeed, that I had been asked to write an article in which I imagine what the next 100 years of medicine might have in store. She laughed and said, “I’ve seen the world go from the horse and buggy to airplanes that hover. When I was a girl, I couldn’t even begin to dream about what we have in the world today.” She went on to tell me that most of the things that I take for granted were things that were absolutely beyond imagination 75 years ago. The twentieth century witnessed more change for human society than any other time in history. What I hope to offer is a look at what I believe are some interesting issues, reflecting both on how I would like things to be, and how I fear they might be.
Patterns of practice
I predict that we will go through a phase in medicine in the near future that will involve what I call the “medical mall.” While shopping for clothes, one will have the option of popping in for primary care consultation. Perhaps the medical mall will grow into a huge health centre. Within its walls would be fitness and recreation facilities, aromatherapy kiosks, all types of specialists, operating rooms, ICUs, acupunc-ture lounges, drug stores, physiotherapy clinics, psychiatric day programs, optometrists, and more.
I don’t doubt that there would be sales and promotional offers, as each locale vies for the health-care dollars that may be directly or indirectly acquired from the patients. Being a physician in this type of practice would be much like working in retail; overhead to a management group, mall working hours, marketing to particular customer groups to encourage repeat business, and so on.
I also believe that the primary care model of a single or small group office will survive and prosper in the next century. Shared space and flex hours will likely increase the availability of services to patients during non-typical business hours, and physicians will be more open to sharing patient care among trusted colleagues, allowing for much deserved and needed time off for family, friends, and healthy living.
I imagine that corporations will employ physicians as primary care givers, and that specialists will be contracted out to several corporations for priority care of employees, much like professional sports teams do now. In this case, the primary care physicians may adopt a practice of “office calls,” delivering health promotion, health monitoring, and diagnostic and treatment services at the workplace of the patient, which would allow corporate productivity to continue uninterrupted.
Surgeons, I propose, will continue to work too much but will provide quality care to their patients. Private surgical clinics with hospitalist partnership allowing full ICU capacity will emerge, and patients who can afford it will attend these practices rather than be cared for by medical students and residents in the publicly funded systems. Radiologists will spend more time at home, providing expert opinion to large territories (possibly internationally) from the comfort of sofas and large monitors and telecommunications equipment in the home.
In the end, the changes in patterns of practice may be problematic and even controversial. However, I expect that they will ultimately serve to increase the availability of services to patients where and when they need it, and to increase the options for physicians to attend to their own personal and family needs.
The business of medicine
For better or worse, I believe that the marketplace will play a role in the evolution of medicine. The government will try to hold the reins of the health-care system, but ultimately the public will demand services that the public purse cannot provide. Right or wrong, universal access to health care will morph into a universal right to a societally acceptable minimum standard of care, and the rest will be for sale. Those patients who want the old-fashioned country doctor who will sit and chat with them, know their whole family, make house calls, and so on, will be able to purchase this type of service if they have the means. Certainly there will be doctors who will want to practise that way, assuming there is adequate remuneration. As a profession, we will have some responsibility to ensure that those who cannot afford more customized service still have access to appropriate medical care.
The business of medicine will also change how physicians are paid. Many more physicians will seek adequately salaried positions with benefits and working conditions that permit a balanced and healthy lifestyle. Doctors who continue to work in the public system will work on a fee-for-service basis for as long as the workload is unreasonable and the working conditions remain unacceptable. Closed communities will develop that will work in a barter system, and physicians in these communities will work for trade of services and products within that community. Others will laugh at these communities and mock their old-fashioned ways. Those within will not care, and they will be happy.
Patients in the next 100 years may have to pay directly for some of their lifestyle decisions. Extreme mountain bikers may have to pay for insurance to participate in their sport, or may be exempt from public treatment of orthopedic or neurosurgical injuries. Smokers may be ineligible for certain types of care, or may have more health deductions taken off their paychecks. This will be criticized as unconstitutional, and an infringement on personal choice. Those in favor will argue that it is not so much a restriction of lifestyle choice, but a requisite accountability for personal choices with a potential cost to society.
The role of primary care
The role of primary care physicians, whether in offices or in emergency departments, will increase in importance, but will be challenged by non-physician health-care providers. Nurses, exercise specialists, dieticians, pharmacists, complementary medical consultants, first-aid attendants, and paramedics (not an exhaustive list by any means) will continue to expand their practices, improve the quality of care that they provide, and will likely produce research-based evidence showing that much of their practice is no worse or better than physicians’ practice. They will learn the information management skills to access the medical literature as physicians do.
They will ultimately argue that they should be recognized as appropriate access points to the health-care system. They will lobby for the right to access diagnostic facilities for their patients, specialty consultation, and the right to prescribe evidence-based therapies just as primary care physicians do. This will be disconcerting and controversial to some of the medical establishment, but it will ultimately serve to improve the quality of care that physicians provide to their patients. The qualities espoused by other health-care providers that are desirable to patients will raise the standards of acceptable outpatient care. Physicians who want to keep their patients will have to incorporate these practices or they will lose their privileged spot as the gateway to many of society’s health care resources.
Lifestyle and wellness
There will come a time when physicians will practice what they preach. More and more, physicians will find patterns of practice that allow for healthy living. However, I must be careful not to appear optimistic about the positive lifestyle choices that my colleagues may make. I believe that our employers, whether government, corporations, or private patients, will overwhelmingly lead the change toward balanced lifestyles among their physicians. Society will no longer tolerate sleep deprivation, ridiculous working hours, and out of shape caregivers telling them to sleep more, work less, and take care of their exercise and diet choices.
Legislation will enforce time off, and the market will select for physicians who at least appear to believe in their own advice. With mandated time off, perhaps more and more physicians will invest their enforced free time in exercise, family time, play, community involvement, music, creative arts, and other types of recreation.
National versus international medicine
Quality health care is an economic issue in most parts of the world. I am not optimistic that we will solve the gross inequity that exists between the rich and the poor in our own country in the near future. Furthermore, I predict that it will take much longer to address the even greater inequities that exist between developed and developing countries. As terrifying as it may sound, I believe that politicians will be the ones who solve these problems. Physicians will continue to be active in politics, but more importantly, I believe that more physicians will be active in their practices at an international level.
I believe that social agencies will continue to provide opportunities for physicians to travel to developing countries to participate in the delivery of health care and the education of health-care providers in these growing communities. I am hopeful that the next generations of physicians will think beyond their own local community to the national and ultimately international communities to which we all belong. We can contribute at the front-line level to making the world a healthier place; we just have to decide to fit it into our lives at some point during our careers.
How long has medical school been 3 or 4 years long? How much information do we still think we can pack into that same finite amount of time? What about residency? Will we continue to force our future to endure years of unhealthy living, sleep deprivation, financial burden, and critically unbalanced lives? There is no arguing that we currently train physicians in an imperfect system.
I envision technology playing a role in decentralizing medical training in the new millennium. I believe that the resources will soon exist to learn the basics of medicine in any location with access to a telephone, coaxial cable, or a satellite dish. I believe that it will be possible to have world experts (and expert educators) delivering the important principles of human biology to medical students from anywhere in the world. I envision clinical clerks learning basic medicine in their home community with preceptors who enjoy and excel in teaching, and who are not overwhelmed by multiple layers of learners in tertiary care settings.
I expect that one day good teachers will be adequately recognized and remunerated for their skill and that research and publication will be valued, but mutually exclusive in the academic world of medicine. I imagine that specialty experience for medical students will be acquired in centres of excellence to augment the basics of medicine that are likely better learned outside of the ivory towers. I anticipate that our health-care community will continue to integrate all professionals in clinical management and education. Classmates will not only be other medical students, but nursing students, paramedic trainees, physiotherapists, acupuncturists, and so on.
I anticipate that patients will become even more highly esteemed as our most important teachers. Problem Based Learning (PBL) will remain as the new and innovative means for teaching undergraduate medicine. I believe that PBL’s strongest educational shift is the focus on learning, rather than teaching (note that it is not called “Problem Based Teaching”). It is inevitable that we will stop trying to be receptacles for knowledge and will begin to identify ourselves as informatics experts; skilled professionals who can access clinical information from computer databases when needed. We will continue to excel in compassionate, empathetic history-taking, physical examination, and ordering and interpreting appropriate investigations. We will have skilled access to databases of evidence-based information and the information management skills to apply that information efficiently in the clinical setting. It is my hope and strong belief that education will continue to change as the field of medicine evolves.
There is little doubt that the future of medicine will be significantly influenced by technology, but from our perspective, technology will have little to do with how we conduct ourselves as health-care practitioners in the future. It would be easy to imagine the future from a solely technological perspective. There will be changes in the way that we communicate, the way that we travel, and of course in the way that we examine patients, investigate their clinical problems, and deliver treatments.
I will dare to go against the grain and suggest that technology will not bring about as much change as we think. As more technology is introduced, it will become our challenge to not only know how and when to use it, but also when not to use it. We will unlearn the distraction of technology and relearn and reinforce the role of a listening, compassionate, and caring physician. It will become our responsibility to preserve the dignity of the individual and value the human interactions that make our profession unique.
A unique form of technology for the next century will be biotechnology. More than any other basic science field, I believe that genetic technologies in the next century will bring about the most controversy. Cloning, antenatal selection, embryo-building, genetic therapies, and, potentially, genetic weapons and gene-specific ethnic cleansing will be possible. Science has been long accused of going where it can go without necessarily considering if it /should /go there. On the one hand, I cannot think of a field more fraught with ethical dilemmas than genetics. On the other hand, I cannot identify an area with more potential to benefit mankind in the delivery of cutting-edge health care. It will be fascinating and possibly frightening to see where biotechnology takes us in the next 100 years.
The fall of science with the emergence of evidence-based medicine
Evidence-based medicine (EBM) is here to stay. Not one of us will have attended an academic teaching session, a grand rounds, or a continuing medical education session without hearing the EBM phrase being tossed around with great, pompous authority: “EBM will establish the righteousness of the science which is medicine.” Ultimately, it will, but that time is very far in the future. In the short term, EBM skills and thinking serve to show us how little we really know, and how flawed the evidence is for the science upon which we already base our practices.
EBM principles will build and strengthen the continued academic output in our profession, but these same principles will also be used against us in the short term to identify how little we know, and perhaps to appropriately undermine our privileged position as gatekeepers in the health-care system. In addition to embracing EBM principles and working collectively as a profession to establish evidence-based care, we will have to nurture the art of medicine. With the fall of the science of medicine, we will need to rediscover the magic of our profession, to embrace it and use it in the care of our patients. We need to remember that the trick in caring for our patients is caring about our patients.
The growth of the science of the spirit—Alternative/complementary medicine
If you are willing to concede that the science of medicine is imperfect, then we must allow for the possibility that some modalities of care that have not or cannot be proven by science may be beneficial. There has been much discussion in my short medical career about the increased use of alternative or complementary medicine by the public. In general conversation with patients, friends, family, and colleagues, I have come to the conclusion that Western (allopathic) medicine probably has the most to offer in acute-care medicine.
Chronic conditions, on the other hand, by their very nature are not well handled by any health-care professionals, allopathic or otherwise (if they were, they wouldn’t be chronic problems, would they?). To some degree, I anticipate that some combination of science and commerce will determine which modalities of care will be favored by society in the next 100 years. I believe that people will continue to seek the advice of allopathic physicians for problems such as trauma, infections, vascular emergencies, poisonings, and surgical problems. However, I believe that patients will increasingly attend many different types of professionals, including physicians, for the management of chronic complaints. Ultimately, the most effective of these modalities will come to form the standards of care for the future and will be adopted by physicians after appropriate applications of EBM principles.
My generation of physicians are inheriting a profession that has fallen from grace in public opinion. Physicians no longer hold an unquestioned, esteemed position, and are now appropriately held quite responsible for their decisions, actions, and their personal skills (or lack thereof). Although I am not disappointed by this, as I believe that respect is earned not endowed by title or position, in the end my job will be harder. I will need to spend more time talking to my patients. I will need to listen more.
I will have to welcome differing opinions into discussions of care with family members, and ultimately, I will have to win the regard of my patients by my professional competence and solid personal skills. That doesn’t sound so bad. That is also what individual physicians have always done to earn respect. Perhaps the fundamental doctor-patient relationship will not change in the new millennium, but will remain a constant that will preserve the integrity of medicine as a profession.
Leaders of the future—the offspring
The field of medicine is not just something that we study and ultimately work in. It is something that we inherit. I feel privileged to have been welcomed into the family of medicine, and I have a responsibility to preserve and nurture the legacy that will be left to me and my generation of physicians. What I have learned is based on centuries of life work of those who preceded me and for that I am grateful.
That being said, inheriting the responsibility for contributing to the ongoing, growing field of medicine does not obligate me to leave it as it is. In fact, it is up to my generation to monitor, evaluate, and ultimately to fix the things that need fixing. One approach to any career is to look at the system one works in, learn it well, and then preserve it. My approach is to look at the principles that guide us in our evolving profession, and modify the system constantly to support those principles within an ever-changing world.
Ramblings about the future are at best interesting and thought provoking, at worst tedious and uninformed. Mine are likely both. I honestly do not know what the next millennium has in store for the field of medicine. What I do know is that I and every physician in practice today, and all those who will follow us, make the future. With direction from our patients, the possibilities for a better future for health care are endless.
Dr Lund graduated from UBC in 1998 and is currently a PGY-2 emergency medicine FRCPC resident at the University of Alberta.
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